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<title>Incident Reporting Form</title>
<link rel="stylesheet" type="text/css" href="view.css" media="all">
<script type="text/javascript" src="view.js"></script> <script
	type="text/javascript" src="calendar.js"></script>
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<body id="main_body">
<img id="top" src="top.png" alt="">
<div id="form_container">
<h1><a>Incident Reporting Form</a></h1>
<form id="form_199158" class="appnitro" method="post"
	action="IncidentReportFormHandler">
<div class="form_description">
<h2>Incident Reporting Form</h2>
<p>Fill this form to report an incident on H1N1 influenza</p>
</div>
<ul>
	<li class="section_break">
	<h3>Patient Details</h3>
	<p></p>
	</li>
	<li id="li_1"><label class="description" for="element_1">Patient
	Name </label>
	<div><input id="name" name="name" class="element text medium"
		type="text" maxlength="255" value="" /></div>
	</li>
	<li id="li_14"><label class="description" for="element_14">Sex</label>
	<div style="float: left"><span style="float: left"> <input
		type="radio" id="element_14_1" name="sex" class="element radio"
		value="M"> <label class="choice" for="element_14_1">Male</label></span>
	<span style="float: left"> <input type="radio" id="element_14_2"
		name="sex" class="element radio" value="F"> <label
		class="choice" for="element_14_2">Female</label></span></div>
	</li>
	
	<li id="li_6"><label class="description" for="element_6">Contact Information</label>
	<div><textarea id="address" name="address"
		class="element textarea small" style="width: 290px;"></textarea></div>
	</li>
	
	<li id="li_7"><label class="description" for="element_12">Birth Day</label><span> <input id="element_7_1"
		name="element_7_1" class="element text" size="2" maxlength="2"
		value="" type="text"> / <label for="element_7_1">MM</label></span> <span>
	<input id="element_7_2" name="element_7_2" class="element text"
		size="2" maxlength="2" value="" type="text"> / <label
		for="element_7_2">DD</label></span> <span> <input id="element_7_3"
		name="element_7_3" class="element text" size="4" maxlength="4"
		value="" type="text"> <label for="element_7_3">YYYY</label></span> <span
		id="calendar_7"> <img id="cal_img_7" class="datepicker"
		src="calendar.gif" alt="Pick a date."></span> <script
		type="text/javascript">
			Calendar.setup({
			inputField	 : "element_7_3",
			baseField    : "element_7",
			displayArea  : "calendar_7",
			button		 : "cal_img_7",
			ifFormat	 : "%B %e, %Y",
			onSelect	 : selectDate
			});
		</script></li>

	
	<li id="li_3"><label class="description" for="element_3">Area</label>
	<div><input id="city" name="city" class="element text medium"
		type="text" maxlength="255" value="" /></div>
	</li>
	
	<li id="li_8"><label class="description" for="element_8">Description
	</label>
	<div><textarea id="description" name="description"
		class="element textarea small" style="width: 375px;"></textarea></div>
	</li>
	
	<li id="li_12"><label class="description" for="element_12">Symptoms</label>
	<div><textarea id="othersymptoms" name="othersymptoms"
		class="element textarea small" style="width: 375px;"></textarea></div>
	</li>
	
	<li id="li_12"><label class="description" for="element_12">Contact History</label>
	<div><textarea id="contacthistory" name="contacthistory"
		class="element textarea small" style="width: 375px;"></textarea></div>
	</li>
	
	<li id="li_12"><label class="description" for="element_12">Travel History</label>
	<div><textarea id="travelhostory" name="travelhostory"
		class="element textarea small" style="width: 375px;"></textarea></div>
	</li>
	
	<li class="buttons"><input type="hidden" name="form_id"
		value="199158" /> <input id="saveForm" class="button_text"
		type="submit" name="submit" value="Submit" /></li>
</ul>
</form>
</div>
<img id="bottom" src="bottom.png" alt="" />
</body>
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